Healthcare Provider Details

I. General information

NPI: 1639301666
Provider Name (Legal Business Name): YOTAM HEINEBERG DOCTORAL CANDIDATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2009
Last Update Date: 08/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2471 E WALNUT ST
PASADENA CA
91107-3394
US

IV. Provider business mailing address

3016 WAVERLY DR 315
LOS ANGELES CA
90039-2052
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-5141
  • Fax:
Mailing address:
  • Phone: 650-305-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: